Provider Demographics
NPI:1104012426
Name:BRACKMAN, JENNITH (OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNITH
Middle Name:
Last Name:BRACKMAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SUNSET TRL
Mailing Address - Street 2:
Mailing Address - City:KINGSTON SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37082-5239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 SUNSET TRL
Practice Address - Street 2:
Practice Address - City:KINGSTON SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37082-5239
Practice Address - Country:US
Practice Address - Phone:615-604-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1651174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist